Expanding the collaborative care model

Most adults in the United States receive mental health care from nonspecialist providers, mainly in the primary care setting. Yet primary care physicians have limited time, and access to evidence-based psychotherapy is especially challenging in primary care practices. Not only is referral to mental health specialists much more complex than to other providers, but patients often choose not to see them. In one small Mayo Clinic study, just half of patients referred to the Department of Psychiatry and Psychology kept their appointments.

An evidence-based alternative to this approach is a collaborative model that integrates mental health professionals and care managers into primary care. More than 70 robust, randomized controlled trials, including the pivotal 2002 Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study, which appeared in the Journal of the American Medical Association, have demonstrated that collaborative care for depression is far more effective than usual care in a variety of treatment settings.

In Minnesota, the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) program for adults with diagnosed depression is based on the IMPACT model. Like IMPACT, DIAMOND adds a care manager and consulting psychiatrist to the health care team and uses the Patient Health Questionnaire (PHQ-9) for assessment at the first primary care visit.

Other program components include systematic monitoring using repeat PHQ-9 measurements and a patient registry, a stepped-care approach to treatment, and a relapse prevention plan. Patients who don't respond to treatment or have an acute crisis can receive same-day specialty mental health care but are referred back to primary care when stable.

Data from Mayo show that many more people reach remission in DIAMOND than those not in DIAMOND do — 26 percent of patients at DIAMOND sites compared with 5.8 percent of patients at primary care and behavioral health clinics combined. Mayo Clinic and other DIAMOND sites consistently report the best depression outcomes in the state.

David J. Katzelnick, M.D., chair of the Division of Integrated Behavioral Health at Mayo Clinic's campus in Rochester, Minnesota, notes the significant effect of collaborative care on adherence. "In the DIAMOND program, care coordinators have weekly follow-up contact with patients where they address adherence and barriers to treatment. Frequent contact — virtually impossible in usual primary care — keeps patients engaged and improves the likelihood of remission," he says.

In 2011, based on the success of DIAMOND, Mayo Clinic initiated a pilot program for adolescent depression called Early Management and Evidence-Based Recognition of Adolescents Living With Depression (EMERALD). The program has received excellent results on all standard patient-reported outcomes, and there are plans to expand it across Mayo's primary care departments. "By treating medical and psychiatric issues in primary care, we can look at the whole person and have real potential to help people by catching problems early on," Dr. Katzelnick says.

Reaching more patients

The next challenge, Dr. Katzelnick adds, is extending collaborative care to patients with anxiety disorders and mental health problems other than depression. One such evidence-based program, the Coordinated Anxiety Learning and Management (CALM) Tools for Living Program, was piloted at Mayo and aims to treat four common anxiety disorders including generalized anxiety disorder, social anxiety disorder, panic disorder and post-traumatic stress.

Dr. Katzelnick is also interested in the development of primary care programs for patients with early substance abuse and chronic pain issues and is currently developing a program for Olmsted County, Minnesota, that would provide integrated care to patients with borderline personality disorder. "We need to think not only about the person sitting in front of us but also about all those who aren't receiving treatment and extend care to everybody," he says. "To do that, we have to work together."

For more information

Unützer J, et al. Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. Journal of the American Medical Association. 2002;288:2836.

EMERALD extends collaborative care model to adolescents with depression. Psych Update. Mayo Clinic. 2012;4(1):1.